What epidemiologic clues should heighten suspicion of a bioterrorism attack?
What is the appropriate organizational response to a suspected bioterrorism event?
What clinical syndromes are associated with possible agents of bioterrorism?
Epidemiologic Features Suggestive of Bioterrorism
Several disease entities should raise the suspicion that a bioterrorist attack is occurring, especially when clusters of similar cases are seen. These include:
- A life-threatening, apparently infectious illness in a young, otherwise healthy person, not due to toxic shock syndrome, meningococcus, or Rocky Mountain spotted fever
- A serious pneumonia in a young, otherwise healthy adult
- Influenza outbreaks occurring during the offseason
- A febrile illness with a widened mediastinum on chest radiography (as seen in inhalation anthrax)
- The characteristic vesicular rash of smallpox
- The capillary leak syndrome of viral hemorrhagic fevers
- Laboratory suspicion or diagnosis of infections due to glanders (Burkholderia mallei), anthrax, smallpox, hemorrhagic fevers
- Plague (Yersinia pestis) or tularemia (Francisella tularensis) outside of endemic areas
- Neurologic findings compatible with botulism
After a proven or suspected bioterrorist attack, a tremendous surge of patients may affect, and potentially overwhelm, many areas of the hospital, including the emergency department, microbiology laboratory, outpatient clinics, and inpatient medical wards. This may include many persons seeking medical evaluation who are unaffected by the bioterrorist agent. It may be problematic to differentiate the “worried well” from patients in the early stages of infection due to a bioterrorist agent. For example, anthrax (and many other infections) may first present as a “flu-like illness.” If there is a recognized bioterrorism event due to the intentional release of B. anthracis spores during a busy influenza season, many people who would otherwise remain at home with influenza are likely to seek medical attention out of fear of inhalation of anthrax.
A bioterrorism event requires an organized, prompt response to mobilize all available resources. Hospitals should have an approved infectious disease emergency management and response plan (as in Figure 266-1) in place for potential bioterrorism agents, as well as for other highly virulent infections, including SARS and pandemic influenza. If the hospital does not have such a plan in place, hospitalists should contact specific services:
- Infection control/hospital epidemiology, to ensure that patients are placed on the proper precautions to prevent nosocomial transmission of infection. These vary with the suspected agent. For some, such as anthrax and botulism, there is no risk of person-to-person transmission. For others, such as plague pneumonia and smallpox, the risk is substantial.
- Public health authorities, to report possible cases (usually done by infection control/hospital epidemiology), and to engage their clinical expertise and laboratory resources.
- The clinical microbiology laboratory, to ensure that appropriate specimens are properly collected and transported, and to ensure that the dangers to laboratory workers are minimized. Bioterrorism agents such as Francisella tularensis, Brucella species, and viruses (including smallpox, SARS, and viral hemorrhagic fevers) are each associated with a major risk ...